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r <br /> �AE- GEIVEL <br /> Spill Bucket Testing Report Form 10111,fr5my 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment stru5NVTimed <br /> Printoutsfrom tests(ifaPlicable), should be provided to thefacility owner/oPeratorfor submittal to the To aT're ?afo'a eric <br /> 8� ►Y g Y <br /> 1. FACILITY INFORMATION <br /> Facility Name: MANTECA EXPRESS MART Date of Testing: 5/28/15 <br /> Facility Address: 419 S. MAIN STREET MANTECA, CA 95337 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:4/24/15 <br /> Name of Local Agency Inspector(if present during testing): MUNI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d Street Galt,CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ® Zane A.Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1 16" <br /> Identif� Spill Bucket(13}' lank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc'.) <br /> ® Direct Bury ® Direct Bury <br /> Bucket Installation Type: ®Direct Bury ❑ Direct Bury❑ Contained in Sum El Contained in El Contained in <br /> Sump El in Sump Sump Sum <br /> Bucket Diameter: I I 11 11 <br /> Bucket Depth: 15 15 15 1/2 <br /> Wait time between applying - _ -- <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1400 1400 1500 <br /> Initial Reading(Rj): 13 3/4 14- 13 1/4 <br /> Test End Time(TF): 1500 1500 1600 <br /> Final Reading(RF): 13 3/4 14- 13 1/4 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ❑ Pass ❑ Fail ® Pass ❑ Fail I ® Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature U _ - Date:-5-28-15 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />